Friday, July 20, 2012

In an election year, it’s hard to criticize the President without someone asking if that means you’re endorsing this guy. But when it was announced yesterday that President Obama will not make an in-person appearance at the 19th annual International AIDS Conference and will instead send a “brief video message” to IAC attendees, conference organizers and global AIDS leaders knocked the President for his seemingly indifferent response to the IAC’s return to the U.S. and failing to demonstrate his Administration’s commitment to fighting HIV/AIDS at home and abroad.

Charles King, President and CEO of Housing Works, called President Obama’s decision not to speak a severe miscalculation. “He is giving up an opportunity to show real leadership on AIDS here in the US and abroad.” The President’s decision to send a video message was a major let down for IAC attendees and came after months of speculation about whether or not the President would make an appearance. With the formal announcement made less than a week before the start of the IAC, which is scheduled to begin on Sunday morning, July 22nd, HIV/AIDS leaders are now calling on the Obama Administration to demonstrate its commitment to battling the epidemic by restoring the proposed cuts to PEPFAR, the President’s Emergency Plan for AIDS Relief and taking steps to reduce the number of people on the waiting list for AIDS Drug Assistance Program (ADAP) which provides medications to uninsured and low-income people across the country.

Others are calling the criticisms leveled against President Obama misleading, redirecting the focus on the HIV/AIDS measures his Administration has overseen. Programs and examples include $1 billion for ADAP programs—an increase of $67 million from previous fiscal years—and increasing funding for the Ryan White AIDS Drug Assistance Program by $75 million. Others champion the drafting and passing of the Affordable Care Act, which will cover many new populations under the revamping of Medicare, including those with pre-existing conditions, children with HIV/AIDS, individuals and families with an income below 133% of the Federal poverty line, and individuals no longer having to wait for an official AIDS diagnosis to be eligible for Medicare.

Is it a mixed bag? Absolutely. It’s undeniable that President Obama’s decision not to speak at the IAC feels like a slap in the face, considering the steady rates of HIV/AIDS infection in the country and the simple logistic fact that the conference is happening in his backyard. Who knows. Maybe he doesn’t want to run into George W. Bush, who is also scheduled to speak at the conference. Let’s hope President Obama’s actions in the next year ring louder than his video greeting.

Friday, July 6, 2012

Ohio’s AIDS advocates and supporters have, once again, been successful in their bid to stave off the advancement of the proposed regulatory changes to Ohio’s AIDS Drug Assistance Program (ADAP). During a recent meeting of the Joint Committee on Agency Review, Ohio’s Department of Health (ODH) pulled the item. In so doing, they identified the need for further review relating to both procedural and business impacts of the proposed changes.

Understanding the Proposed Changes

As discussed in previously, the proposed changes altered both the medical and the financial criteria which needed to be met in order to qualify for treatment under ADAP. Crucially, the proposals included reducing the qualifying CD4 count from 350 to 200, and reducing the financial means test qualifying level to as low as $11,000.
As per the ODA, the proposed changes were intended to address the shortage of available funds in place to support Ohio’s ADAP. The ODA indicated that, by altering the program’s eligibility criteria, and in turn reducing the numbers of HIV positive patients entering the program, funds could be more effectively targeted so as to ensure that the treatment of the sickest and most vulnerable patients was possible.

In the months preceding the review meeting, much criticism had been levied at the above proposals. This criticism has come, not only from patients, but from religious groups, community groups and medical practitioners alike. As per the critique from Tom Myers, General Counsel for AIDS Healthcare Foundation:

"Changing Ohio’s medical-eligibility criteria for its ADAP, such as reducing the qualifying CD4 count from 350 down to 200, as this rule change does, is actually a form of rationing of lifesaving HIV medicines".

Dr. Thai Nguyen, an AIDS Healthcare Foundation medical provider, who is responsible for the care of over 400 HIV/AIDS patients, stated:

"While we recognise that there is a shortage of funds in the Ohio HIV Drug Assistance Program, and the ODH is trying to put in place measures to ensure that those who are the sickest have access to antiretroviral medications, I argue that adding stipulations to ration antiretroviral medications is an act that directly contradicts ODH’s mission statement, the core principles on which it operates and the national and international scientific consensus on the treatment of HIV".

Pulling the Reforms: What does it mean for HIV-positive patients in Ohio?

This week’s news that ADAP reforms would be pulled for further review is doubtless good news for Ohio’s HIV/AIDS advocates. Indeed, it represents their third victory against the reforms in six months. As per Eddie Hamilton, founder of the ADAP Educational Initiative:

"We are thrilled that this item was pulled from the JCARRS meeting agenda earlier today".

Thus, for the time being, the program’s eligibility criteria remain unaltered. Moving forward, however, the Ryan White Program is due for re-authorization in 2013 and the ODH has not committed itself to the status quo; rather to further policy review. As developments are so recent, there is little literature which speculates on the outcomes of this likely policy review. Any such review is, however, likely to focus on several key policy factors.

The Increasing Numbers of HIV Positive Patients

There is concern that the number of people testing positive for HIV-infection is on the increase. This has led some to describe America as suffering from an AIDS epidemic. Figures collected for the State of Ohio in during 2008/9 identified 16,283 people as HIV positive, and estimated at an additional 5000 undiagnosed cases. Additionally, 7,613 Ohians had received an AIDS diagnosis, representing 7.8 per 100,000 Ohians. Thus, any alternative proposed reforms must address both the need to provide for increasing patient numbers and the need to identify epidemiological demographics so as to target treatment.

Financing Treatments

Though some HIV-positive individuals in Ohio are holders of private medical insurance, many are not. Thus, it is crucial that the State reforms direct funds towards those who are not able to access treatment through another means. Nationally, Medicaid is a primary funding source for the treatment of patients with advanced AIDS diagnosis, as qualification for funding is based upon the ability to prove permanent disability. Childless adults who are HIV-positive may not, however, qualify for Medicaid. For these adults, the ODH’s Federal Ryan White HIV/AIDS program offers limited coverage. The status and provision for adults treated under the Ryan White program is likely to be a focus of ODH reviews.

Match Funding Requirements

Any review of funding must factor in the need for States to match Federal funds with their own resources when supporting patients under the Ryan White Program. With the Ohio AIDS Drug Assistance Program constituting the largest part of the Ryan White Part B Program, completion of a comprehensive match funding exercise will be essential.

Medical Need

The biggest criticism levied at the ODH’s previous attempts to reform the ADAP have centred on the adjustment of support thresholds. As per the ODH, the purpose of these proposed adjustments was to enable staff to direct treatment towards their least well patients. In a review, the ODH must consider both the ethical and the long term financial implications of not treating diagnosed patients on a timely basis.

Healthcare Reform 2014

Reforms of the ADAP must be considered alongside the major reforms which are expected within the Affordable Care Act (ACA). As the ACA reforms will significantly impact upon several important HIV/AIDS programs, reforms of the ADAP must be forward looking. Emphasis must be placed on ensuring that, post ACA reform, a safety net remains available to individuals who are HIV-positive.

Implementation of the National AIDS strategy

President Obama’s National AIDS Strategy aims to reduce the number of people who become infected with HIV and strives to increase access to care for those who are infected, in turn, improving their health outcomes. Further, it aims to increase consistency of care, reducing regional disparities within treatment programs.
The strategy is accompanied by a Federal Implementation Plan, which identifies steps to be taken by Federal Authorities during the implementation process. The plan sets out key goals, which should be considered by the ODH when reviewing HIV policy decisions. For example, the plan states that US Federations should aim to:

‘Reduce the HIV transmission rate, which is a measure of annual transmissions in relation to the number of people living with HIV, by 30%’.

When reviewing funding and medical eligibility specifications under the ADAP, the National Aids Strategy should be considered. This strategey encourages Federal Governments to take a more strategic, streamlined and comprehensive approach to reforms. For example, by developing sound HIV awareness campaigns and increasing access to STD Kits, the OHD could reduce the spread of infection, which in turn could free up resources for individuals who test HIV-positive.